Nuances of Project Management: A Physician’s Experience

by Dr. Richa Uppal

Calvin: They say the secret to success is being in the right place at the right time. But since you never know when the right time is going to be,
I figure the trick is to find the right place and just hang around! 
Hobbes: Being with you, it’s just one epiphany after another. 
     (from The Days Are Just Packed by Bill Waterson)

The objective of project management is to provide the foundation and structure for repeatable project success. As a physician asked to take a leadership role in restructuring and standardizing workflow at our institution, I was able to apply some project management principles to a process improvement project. My objective is to share my journey in order to bring it alive for other physicians, who may not have been introduced to this powerful tool, and may benefit from it. Often in the healthcare field, outside consultants and IT professionals design changes which impact the daily work practices of physician and nursing staff. While this brings needed skills and professionalism, it can cause knowledge loss and lack of alignment with the organization’s overall goals. Consequently, it would be useful to start building project management competency within the healthcare profession.

I had taken an elective in project management as part of my Master’s program in clinical research at Oregon Health Sciences University (OHSU). OHSU is unusual among medical schools, to offer courses in project management. Around the same time, I was asked to chair a team to standardize workflow for rooming patients.  Patient rooming is a pre-visit preparation process. It involves obtaining records for emergency room and specialist visits, medication information, preventative health screening tests, vaccination and social history, and then taking the appropriate vital signs in preparation for the Doctor’s visit. When this is an efficient process, the doctor can focus on treating the patient, instead of looking for information or materials and wasting time and healthcare dollars in the process. It would be analogous to having executives research meeting venues and make their own travel arrangements while being paid top dollar.

Our leadership council had determined that standardization of nursing activities in preparing for a physician visit would be the first step toward streamlining the clinical workflow. This project was mandated after a switch to a new complex electronic medical health record (EMR), when it became evident that the current workflow was grossly inadequate.  Physicians were spending a lot of time entering data in EMR that could be collected by nursing staff. A twenty-member process improvement (PIT) team was created, which consisted of two senior partners, their staff, six nurse managers from each branch of our institution, a Human Resource Manager, an IT and electronic health record specialist, and the Chief Information Officer. Six months into its inception, I was asked to join—the co-chair left a week later.

Our institution consists of approximately 100 doctors in a multi-specialty practice. Our objective was to standardize the rooming procedure when a patient schedules a visit. This process starts before the patient walks into the door, and while pre-visit preparation is a prerequisite for all visits at all offices, there is no uniformity across clinics or physicians. As a result, one physician can see many more patients in a day, provide excellent care and return home on time, while another is behind schedule and works late. Our desired outcomes were to achieve an efficient visit for the doctor, nurse, patient, and to provide excellent patient-care at the same time, creating a better and safer patient experience and improving the quality of care.  Another driver was the need to save money and time. These could be achieved through proper delegation, and better use of resources so that the doctor is not required to gather data and can focus on the primary task of medical decision-making while the nursing staff are able to apply their critical-thinking skills instead of serving as clerks.

Prior to this, I contributed ideas in quality improvement meetings and committees. I was fairly new to the organization, having been there for only about two years in the role of a primary care physician. It was a position of influence without authority. I did not feel particularly well prepared, but jumped right in. We were not assigned a specific deadline but I decided to interpret it as a “project” with a finite end point. By using project management methods, it was easier to create structure and a road map. We developed a charter (clear objectives), established a sponsor (an entity to report to), set goals and a budget, used PM tools to conduct meetings, developed a responsibility matrix (who was assigned a task and when was it due), and worked within our timeline.

Lessons Learned

The following examples highlight some of the key lessons learned from the project:

Managing the Fuzzy Front End

The beginning is often murky, with no clear roadmap. I decided to go to the team meetings armed with a PowerPoint presentation of key concepts from my Project Management class, and use them to stimulate discussion and create structure.

We planned to observe the rooming processes of our highest producing physicians to understand best practices and extrapolate them to other physicians. We hosted a contest for staff to elicit ideas that they would then practice applying to their existing routines. We used them in our protocol and rewarded the top ideas. This served to boost staff buy-in to the process. Lastly, we conducted a physician survey that addressed key stakeholders to elicit expectations from the staff. As a result of these steps, the physicians were more engaged, invested in, and receptive to the standardization process. This was a positive step; most doctors do not like standardization and see it as interfering with their autonomy.  The nurse facilitators also visited key institutions to develop benchmarks and conduct short pilot studies.

Formulating a Work Breakdown Structure

The work breakdown structure (WBS) is the foundation of project management planning, as it breaks the project down to small and manageable units of work. It helps each person take ownership of what is required to accomplish a task. I had put the WBS on our agenda for two consecutive weeks; however, I was new to the process, and was not confident about executing it with a group of managers and physicians. I rationalized my decision by thinking that we had a high-performing team and did not need need this exercise. I  decided to skip a bungled attempt at the WBS.

If we had to add steps to the staff workload, we were forced to remove other duties that would disturb workflow, such as answering phone calls. The nurse managers decided to conduct a short pilot, forwarding calls to a makeshift call center. Soon, we discovered the need for a script for the phone messages, logistical details regarding housing the staff, and additional equipment. We would have identified these needs earlier, had we formulated a WBS. This pattern continued during our project and led to frequent changes of course.

Stakeholder Management

In our effort to analyze how extra rooming items would affect staffing, a team member was assigned the task of estimating effects on staffing and obtaining financial data regarding the cost of hiring medical assistants. A few days later, I was summoned by our CEO regarding his concern that we were moving in the direction of increasing overhead by recommending more hires. This was not our goal; we sought to make the process more efficient with existing staff resources. I was forced to think about this call in light of another key principle of PM: managing stakeholder expectations. The CEO was not directly involved in our project, however he had a stake in it. He was emailed a copy of the meeting minutes after subsequent meetings. Our efforts were validated when he acknowledged the efforts of the PIT team in a company-wide email a few weeks later. This experience confirmed that a strategy should be in place to keep overlooked stakeholders aligned with the project’s objectives, otherwise any project, however important, can die an untimely death. Maintaining stakeholder buy-in is necessary so that the changes required to meet the project objectives provoke less resistance.

Communication and Conflict Management

By this time, we had initiated a contest for best practices. Long entries, often pages long blended in my mind as they did for the other team members. We voted on the entries, but could not agree on the results. I was concerned that some key entries were left out and questioned the validity of our methods and results. Other members were concerned that I was being autocratic, and thought that I should heed the vote of the team.  We had a long chain of email communications and disagreements, and ultimately a physician called me and suggested we give prizes to all entries that had garnered four or more votes. My lesson learned from this experience was that disagreements should be managed in person, and not by email.

My instinct told me that we needed damage control.  I also met with our project sponsor, the Chief Medical Officer. He gave me feedback and indicated that team members were appreciative of my hard work, but did perceive too much control.  I started writing a milestone summary outlining the accomplishments including the goodwill and publicity earned to make our project successful in the long run, and emailed it to my team. I spoke with my faculty advisor at OHSU who had taught the PM course, and who had been reviewing my progress all along. He agreed that it was time to “fall on your sword” and apologize.  He also suggested using a meeting to “debrief” after a stressful event, to validate concerns that had been expressed by the team members. He discussed accountability and the reasons why our team composition and fairly large size would have affected this hands-on project.

At our last project meeting, two nurse managers conducted a debriefing session focused on what we did well and where we could improve next time.  During the meeting, most team members voiced the opinion that the team had not anticipated the extent of data that would come out of the best practices contest. We also discussed the effect of turnover.  The debriefing meeting helped to rebuild relationships that had been strained in the course of the project. We acknowledged our well-run projects and those that did not go as smoothly—and we celebrated its completion. We were able to successfully create a standard pre-visit checklist which was our objective. We made upstream changes during patient registration.  This included modifying telephone reminder scripts that advise patients to bring medications and other information, to allow our downstream process to run more smoothly. We provided summaries of our pilot project on a centralized call center, other ideas to improve visits and pre-visit preparation, to the leadership council. Team members created training modules for accurate medication review, and to look at overdue preventative health orders during rooming. These were used by the nurse managers to roll out our new rooming checklist effectively. Another measure of success was physician productivity three to six months after completion of the project and transfer to operations. Success in this outcome is expected to translate to more patient visits and increased productivity by at least 10%. This objective has not been studied yet.

Conclusion

While going through the process, I was focusing on using the PM tools but I missed some key methods and concepts. The work breakdown structure would have been helpful to facilitate greater autonomy and ownership by each of the project team members.  I also made the classic mistake of a novice—to under-estimate the importance of relationships and communication building, and to think that they were not critical as long as the work got done. I realize in hindsight that many team members could have contributed more and team dynamics could have been much improved, had I developed a better relationship with long-term employees and managers who were relatively unknown to me, or had I organized more team-building activities. The team would have been more accepting of my “roll up the sleeves and let’s get to work” style. Facilitative management would have been ideal.  Our project was completed within budget and on schedule and has been launched successfully within our institution, however I now appreciate the nuances of project management far more. With my new-found wisdom and battle scars, I look forward to my next project, next epiphany, and the continued use of project management methods and tools, to simplify and streamline work as a healthcare professional.

About the Author

Dr. Richa Uppal practices Internal Medicine at the downtown Portland Clinic. She attended medical school at Manipal University in India, and completed her Internal Medicine Residency at New York Downtown Hospital. After moving to Portland in 2010, she completed a Master's in Clinical Research from OHSU. "I believe in a common-sense approach to medicine, one where the provider collaborates with the patient to achieve great physical and mental health. I try to stay on the learning curve and improve continuously, so I can provide the best care to my patients. I have a special interest in LEAN, project management methodologies and professional communication in the setting of health care.”

You can reach Dr. Richa Uppal at:  RUppal@tpcllp.com